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Just last week, Wil tackled some pressing questions about what our insulin needs are and how it actually works. Today he explores another aspect of this BG-lowering elixir as it works (or doesn't) in people with diabetes (PWDs): insulin resistance, and whether you can be living with two types of diabetes at the same time.

Michelle, type 1 from Louisiana, writes:Can you explain the difference between type A and type B insulin resistance? I'm currently taking over 100 units per day, and my doctor thinks I have both type 1 and type 2 diabetes, but after doing a little research, I am wondering if I have one of these types of insulin resistance. Also, is it even possible to have both type 1 and type 2 diabetes?

Wil@Ask D'Mine answers: You can have multiple orgasms, but can you have multiple diabetes? Some people believe it's possible, and the name "Double Diabetes" has even been brandied about for the "condition." But while I guess it's possible, I don't think we'll never know for sure, and it wouldn't matter much even if you did.

Huh? OK, bear with me.

Let's start with why you might have a pair of double-Ds but why I don't think you can ever be sure if someone has "Double Diabetes." We have a number of chemical markers for type 1 (GAD antibodies and the like). If you have crazy-high blood sugar with the markers, you're a type 1. If you crazy-high blood sugar without the markers, you're a type 2. In theory, if you had both types of diabetes, you'd need to look for type 1 markers along with the signature aspects of type 2. But what would those be? Well, type 2 is a disease of insulin resistance, and type 2s tend to use heaps more insulin than us type 1s, so the best clue might be insulin volume. But this can be misleading, as the amount of insulin anyone person with diabetes needs is highly variable. I know some type 2s that use very little. I know some type 1s that need a ton.

So I don't think we can sort out the biochemistry to find type 2 lurking beneath the type 1 if it is there. But like I said, it's moot. If the pancreas has left the building it doesn't really matter if type 2 is in the house too.

We know what we have to do.

As to the insulin resistance, neither A or B are the kind of insulin resistance we think of when we talk about the insulin resistance in type 2 diabetes. Both types A and B belong to the realm of "extreme insulin resistance syndromes" which includes, no kidding, leprechaunism.

Type B is a rare autoimmune disease that impacts insulin receptors. In plain English, this results in insulin resistance on steroids, requiring massive doses of high-potency insulin. Type B usually shows up in the setting of rheumatologic illnesses such as lupus or Sjogren, and carries a host of nasty side effects. It isn't medically correct, but if you thought of it more as an insulin allergy, you wouldn't be too far off base. Type A is similar in presentation, but is biologically different in that there are no detectable anti-receptor auto-antibodies.

Type A is most commonly seen in lean adolescent females with a host of androgen issues and hormonal imbalances. Type B folks are more commonly middle aged with a list of health issues that would take me ten columns to explain in plain English.

Bottom line: I do pity anyone who has either, but frankly, for those that do, diabetes is just the tip of the iceberg. If you had either, you'd have so many health issues that it would make the Mormon Tabernacle Choir look like a Barber Shoppe Quartet.

Now, as to you. Frankly, my dear, 100 units a day isn't all that scary. It's a lot for a type 1, sure, but by no means unheard of. Most type 2s take at least that much, often more. Once you get over 250 or 300 units a day, conventionally resistant folks are switched to U-500 (which in recent years has proved a major finical boon to Lilly Diabetes), an insulin that's 5x more potent than the "standard" insulin that we're used to. I have one guy who takes 160 units of U-500 a day, that works about to 800 units of "standard" insulin. That's the wonderful thing about insulin: There's no maximum amount, ya take what you need.

By comparison, how much insulin would someone with type B resistance need? Well, I found one case report from UC Davis where the patient needed 1, 225 units per hour via IV drip to hold the DKA coma at bay, and was sent home on a U-500 dose of 1,500 units three times per day! In "normal" insulin that would translate to 22,500 units per day!

You, my 100-unit-per-day gal, do not have type B insulin resistance!

Bill, type 2 from Colorado, writes:I thought I remembered reading somewhere that there are some special insulins in the works for people who are very insulin resistant, but I can't recall where I saw it. Do you know anything about this?

Wil@Ask D'Mine answers: You betcha! Right now, if you need more than 250 units of "standard" U-100 insulin a day, the default is a super-concentrated version of good'ol Humulin "R," called U-500, that we talked about above. But the growing waistlines of the American D-population have insulin makers seeing big profits, so there are a number of concentrated "modern" analog insulins in the works.

You may remember Mike's post earlier in the week, which has some of those details... But I'll point to a couple highlights.

In the first quarter of this year, Lilly actually submitted to the FDA a U-200 version of its fast-acting Humalog insulin, a twice as concentrated version of what's currently on the market. We'll see how long it takes to actually get this product to patients.

Meanwhile, the friendly folks at Sanofi are working on a U-300 version of their blockbuster basal insulin Lantus and Novo has a U-200 version of degludec (a.k.a. Tresiba) their new basal that hit the rocks with the FDA this spring. (But with degludec's future on hold, there is no guessing when we might see the more potent version of it.)

Of course, the action isn't limited to the big players. Little Biodel is working on a U-400 product that would apparently rival Lilly's U-500 for those PWDs who are "severely insulin resistant."

So all this variety is good news right? Uh... Maybe. I see at least one dark cloud on the horizon. (Sorry, it's in my nature to spot dark clouds.) As it stands now, pharmacists get tied in knots over U-500. They worry about dosing errors with two "flavors" of insulin.

Can you imagine how much Maalox pharmacists will go through in a world with U-100, U-200, U-300, U-400, and U-500 insulins?

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.

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